┃Source: China Medical Insurance
Medical insurance payment is an important part of the management of basic medical insurance, an important lever to regulate medical service behavior and guide the allocation of medical resources.
At present, there are mainly the following payment methods for basic medical insurance in China: payment by service item, payment by service unit, payment by head, payment by single disease, payment by disease diagnosis related grouping (DRG), payment by disease classification (DIP), etc. Among them, paying by service is the earliest and most widely used payment method.
Since its establishment more than three years ago, the National Medical Security Bureau has continued to promote the reform of medical insurance payment methods, improved the modernization level of medical insurance governance, explored the establishment of an effective and efficient medical insurance payment mechanism, and successively carried out DRG payment pilots in 30 cities and DIP payment pilots in 71 cities, achieving phased results.
DRG payment refers to the payment of diseases according to the relevant groups of disease diagnosis, and the diseases are divided into different groups according to the severity, complexity of treatment methods and treatment costs, and the medical insurance payment standards are formulated. In general, the more serious the disease and the more complex the treatment, the higher the medical insurance payment standard. DIP payment is paid according to the score of the disease, which is to use big data to use the disease according to the combination of "disease diagnosis + treatment method" as the payment unit, combined with the total amount of medical insurance funds to determine the payment standard of each disease, and pay the hospital according to this standard. Compared with the traditional method of paying by service items and receiving all according to the order, DRG/DIP payment is based on the cost calculation of the data over the years and the same price for the same disease, and the package payment is implemented, which is more in line with the characteristics of different medical services, pays for the price of medical services, and can also promote the continuous refinement of hospital management level of medical institutions, standardize the behavior of diagnosis and treatment services, actively improve the technical level, and provide patients with better medical experience and diagnosis and treatment services.
The promotion of the reform of payment methods has not only improved the efficiency of the use of medical insurance funds, controlled the unreasonable rise in medical expenses, and enhanced the cost awareness of medical institutions, but also played a role in regulating the medical service market to a certain extent, promoting hierarchical diagnosis and treatment, and forming a scientific and orderly medical pattern. It has effectively promoted and supported the healthy development of medicine and health, significantly enhanced the sense of medical access of the masses, and taken a solid step on the road of achieving high-quality hospital development, high-efficiency governance of medical insurance, and high-quality medical treatment for patients.
Recently, the National Medical Security Bureau issued the "Three-year Action Plan for the Reform of DRG/DIP Payment Methods" to promote the reform of DRG/DIP payment methods from partial to comprehensive, from partial to whole, from extensive to refined and in-depth development, and clearly requires comprehensive coverage in four aspects: overall planning regions, medical institutions, disease groupings, and medical insurance funds. Improve the working mechanism, strengthen the infrastructure construction, coordinate to promote the supporting reform of medical institutions, fully complete the task of payment method reform with DRG/DIP as the focus, and comprehensively establish a new medical insurance payment mechanism that is unified nationwide, up-down linkage, internal and external coordination, standards and norms, and effective and efficient.
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